OPINION
There has been a remarkably muted level of public critique so far of the Government's health reforms, where it intends to merge the 20 District Health Boards into one big health monopoly.
It's worth discussing. This is quite probably the single biggest merger New Zealand has ever seen. The organisational change and dislocation will be massive, distracting senior managers and clinicians from their primary jobs of treating people for an extended period. And all during a pandemic.
The current regionally-based organisations between them employ 75,000 full-time equivalent staff and the total head count is considerably higher. Compare that with the 20,000 who work for our biggest company, Fonterra, and you get a sense of the scale of change. The merged organisation will be in charge of some $12 billion worth of healthcare.
Some commentators have praised the announcement because "at least it's bold". Bold reform might be an antidote to political boredom, but if boldness is your criterion for whether a reform is worthwhile, you are setting a very low bar.
The real question is whether the myriad risks and disruptions that come with this grand experiment in re-centralisation will be worth it for the rewards which will follow. The evidence is minuscule in this regard.
One of the more notable aspects of the change is how little has been said about what patients and the public will get out of it.
The minister has made no commitment to reduce ED waiting times, improve the speed of cancer treatment, increase the number of elective operations, improve mental health services or anything else which people look to their health services to do.
His oft-repeated talking point is the change will "end the postcode lottery", meaning people will get equal access to healthcare all over the country. Leaving aside the fact that no evidence is advanced for this, and that people in Taranaki, Gisborne or Otago won't believe a Wellington-based monopoly will deliver better healthcare to them than the current set-up, what does he mean by equal?
If we mean striving for excellence and actively comparing performance in different regions as a way of encouraging better results, that would be one thing, but a centralised opaque monolith generally means the opposite.
And we need to remember the first action of this Labour Government in health was to cancel all public performance measurement.
The Government's record in executing complex policy objectives means there is a high likelihood health services will get worse rather than better. Any government would struggle to pull this one off. And the Ministry of Health is hardly the paragon of public policy execution it will need to be to achieve a good result.
And the minister hasn't finished yet. He's publicly musing about the Government taking over everyone's local GPs as part of his reforms!
I speak with some experience in public service mergers. The merger of four departments into the Ministry of Business, Innovation and Employment back in 2012 was big news at the time.
But it involved a combined head count of only 3000 and we were disrupting policy analysts, not doctors and nurses making life and death decisions. Nevertheless, there were complex execution risks, and looking back, much of management took their eye off the ball for a couple of years as they decided where everyone sat.
The other large scale mass re-centralisation this Government has embarked on is the merger of 16 regional polytechnics and the nationalisation of the industry training sector into the New Zealand Institute of Skills and Technology. The signs there are not auspicious.
The only visible thing the new entity has done to date is build an expensive new bureaucracy over the top of the old one.
It has employed seven top staff in the corporate suite who split more than $2.3 million in salaries between them, while chief executives around the country have been offered third-tier roles which many are refusing because they no longer make decisions about how their organisations serve their regions.
$121 million has been allocated just to re-organise these deckchairs, much of which will support the consultancy industry. Two years into the process, many stakeholders say there is no point engaging with the new national polytech because it is still "sorting itself out". It is around 8 per cent of the size of the planned health merger.
I'm not against structural change in health. Nor would I pretend everything is perfect. For a start, some of the smaller DHBs like the ones in Palmerston North and Wanganui, or Gisborne and Hawke's Bay, could be safely merged to create greater scale to better serve their communities. And it's crazy that Wellington and the Hutt Valley have two separate DHBs.
Board elections are an inordinate waste of time given how few people vote for them. Their chief achievement seems to be to help discourage people from participating in local council elections, with which they share a ballot paper.
Appointed board members with experience in governing complex organisations, jointly agreed by government and local authorities, would seem to be a more sensible and respectful way to ensure local accountability and control. Ironically, even these minor tweaks would have previously caused a political war with the newly-centralising Labour Party.
Given the very high risk and low reward in large mergers, it is hard to divine reasons for all this drive for recentralisation. One clue might be that the public service unions are conspicuously in favour, despite the disruptions their members will experience.
The polytechnic and health mergers will of course give unions more leverage than before. Shutting all the polytechs nationally or the whole health system in support of a wage negotiation is more attention-getting than an individual polytech or hospital.
Another reason could be this Government's innate distrust of any activity they don't directly control and direct.
We need far greater justification for such a monumental change.
The minister should be asked to come up with a business case with quantifiable gains for every New Zealander before plunging the health system into a years-long period of administrative upheaval.
That's the least we should expect before proceeding with this massive merger.
Steven Joyce is a former National MP and Minister of Finance
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